“Patients with anxiety/depression symptoms experienced more pain severity and more pain-related functional, social, and emotional disability, and they were less satisfied with care, compared with the other groups,” the authors write in Pain Management, online July 11.1

“Patients with CLBP have tremendous fears of loss of function. When there are no answers, they quickly become hopeless and feel very vulnerable. This leads to higher rates of depression and anxiety,” Dr. Lisa DeStefano, who was not involved in the study, tells Reuters Health by email.

“I hope that these findings help researchers understand the importance of defining and addressing the etiology of low back pain. This would eliminate/address the exacerbations and will diminish the anxiety and depression that is inherent in CLBP,” adds Dr. DeStefano, who chairs the Department of Osteopathic Manipulative Medicine at Michigan State University College of Osteopathic Medicine in East Lansing.

Dr. Luis Filipe Ribeiro de Azevedo of the University of Porto, Portugal, and colleagues examined baseline and one-year follow-up data collected by four pain clinics from patients who participated in a large observational, prospective cohort study.

The 284 adult patients with CLBP with radiculopathy averaged around 60 years of age and were at their first pain clinic consultation. Patients with cancer pain, psychiatric or cognitive disorders that might affect data collection and those unable to communicate in Portuguese were excluded.

In an in-person interview at baseline, participants provided details of their sociodemographics, medical comorbidities, and pain coping strategies, and the researchers extracted data from the clinical chart. The patients were interviewed again by telephone one year later.

Anxiety and depression symptoms were evaluated using the Hospital Anxiety and Depression Scale (HADS), and outcomes were assessed using the Brief Pain Inventory (BPI) and the Shortened Treatment Outcomes in Pain Survey (S-TOPS). The authors used linear mixed effects models to assess the impact of anxiety and depression and their interactions on treatment outcomes.

At one year, the 146 patients with both anxiety and depression experienced higher pain severity (P<0.001) and interference (P=0.013) in the BPI, compared with the 61 patients with anxiety only, the 19 with depression only, or the 58 with no symptoms. In the S-TOPS, their pain-related upper-body disability was significantly higher (P<0.001), and their satisfaction with care and with outcomes was significantly lower (P<0.001 for both).

“From my clinical experience,” Dr. DeStefano says, “patients with CLBP reach a degree of hopelessness when their pain is not addressed despite multiple therapies. Often it causes them to seek more and more care and therapies out of desperation. This makes them feel vulnerable and desperate and feeds their hopelessness.”

“It is very important to address patients’ fears about loss of function while simultaneously defining the individual etiology of low back pain in the acute setting,” she advises, adding, “it is important to manage low back pain as any chronic illness, reducing the frequency of exacerbations. This will not only lessen anxiety and depression, it will also decrease cost of care.”

Dr. William E. Gusa, vice chair of pain management at the University of Mississippi Medical Center in Jackson, says by email, “Unfortunately, insurance coverage for mental health in the United States is variable and patients frequently don’t buy in to that concept. Once they hear you recommend treatment for anxiety and depression, they jump to the conclusion that you believe it is only in their head.”

“If these results would make it into the non-medical word, maybe patients would be more open to mental health interventions in conjunction with pain treatments,” says Dr. Gusa, who was not involved in the study.

The authors recommend more individualized intensive CP management for these patients, possibly before or along with other interventions. And they recommend further research to explore how generalizable these results might be to patients with other CP conditions, to identify other predictive factors, and to develop screening tools.

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